DDX Flashcards
LOFTSEA In assessing PC
Location: R/L eye, which VF
Onset: Time frame
Frequency: how often
Type: how bad are symptoms, type of pain
Self-treatment: What helps symptoms
Effect: how does this affect lifestyle
Associated signs and symptoms: relationship to alternate disease
Components of case history
PC: presenting complaint
POH: ocular history
FOH: family ocular history
FMH: family medical history
GH: general health + medication
VT: Visual tasks (hobbies/driving)
Screening questions in PC:
How is D/I/N vision
Age/effect of correction
Sore/red/itchy eyes
Flashing lights/floaters
Headaches
Double vision
PC refractive error:
Binocular blur
Squinting
Headaches
Esotropia > diplopia
Far/near working distance
Hyperopia PC:
Asymptomatic (latent)
Blur near>dist
Strabismus > amblyopia
Asthenopia / headaches
Loss of concentration
Astigmatism PC:
Blur at all dist
Asthenopia / headaches
Squinting
Poor focus
Light haloes
Presbyopia PC:
Blur at near
Asthenopia / headaches
Fatigue
Increased working distance and light level
Ocular disease in cataracts:
Inflammation (uveitis) > PSC
Corticosteroid use > cataracts
Vitrectomy > ascorbate loss > oxidative stress
Nuclear cataracts:
Most common
Accumulation of high weight aggregates > hardening (sclerosis)/^RI > scattering > VA/contrast loss/myopic shift
^fluorescent chromophores > nuclear brunescence > blue-yellow color defect (Tritan)
Cortical cataracts:
Hydration of cortex > subcapsular vacuoles > ray like transparent liquid spaces > decrease in soluble proteins/^insoluble proteins > opacification of rays > cuneiform opacities originating from periphery
Localized RI change > astigmatism
Glare in night (greatest glare)
PSC:
Age/Stress/UV/H2O2/cytokines > dysplastic epithelia migrate to pos. pole > collate with adjacent fibers > balloon cell formation > dysfunctional Na/K ATPase > swelling > intercellular/interfiber vacuoles and extracellular granular material formation > disruption of regular lens organization > light scatter
Vacuoles in flux
Near/light VA worse than far/dark (miosis)
Slit lamp examination of DED:
Lid hyperemia
Tear film debris
Conj. Hyperemia
SPEE (superficial punctate epithelial erosions)
Meibomian capping (MGD/bleph.)
Tear meniscus (reduced in ADDE)
DED symptoms:
Pain/burn/grit/FBF
Watering (CN6 activation)
Hyperemia
Lid fatigue
Intermittent blur (better on blink)
Struggle on screen use (blink rate 11/m > 4/m)
Photophobia
Blepharitis:
Lid inflammation from Staphyloccal or dermatitis
Ant. Affects zeis glands/lash follicles (crusty scales) > bleph debris decreases tear quality
Pos. affects meibomian glands (meibum capping) > EDE + inflammatory mediator passage from lid
DDX dry eye:
Allergic conjuntivitis: itchy
Blepharitis: lid crusting
Pharmacological: medical history
Neurotrophic keratopathy: corneal sensitivity test
Pterygium/pingueculum
CLARE
BCC symptoms:
Superficial: well defined red patch. Slow growth, w/crusting and irritation
Nodular: Pearly/translucent/skin c./pink papule/nodule. Growth > rolled edge w/central depression > ulceration w/bv
Morphoeic/sclerosing: white/waxy patch from longstanding presence
Locally invasive, rarely metastatic
SCC presentation:
Erythematous, tender papule/nodule. Commonly presents as ulcer with hyperkeratosis/horn.
Lesion expansion > recurrent ulceration/bleeding
Pterygium symptoms:
Wing fibrovascular growth at 3/9o’clock, from limbus over cornea. Can form iron deposition at boarder (Stockers line)
WTR astigmatism when on visual axis, can flare up
Signs of conj. Naevi developing into malignant melanoma:
Development post 20y
Sudden onset / rapid growth / pigment change
Abnormal location (fornices/palpebral conj.)
Increased thickness w/feeder BVs
Signs of choroidal naevus forming malignancy:
Growth
Blur, metamorphospia, VF loss, photopsia
>5mm diameter, >1mm deep
Presence of orange lipofuscin
Near OD
Associated serous RD
Differentiation between naevus and melanoma:
Asymmetry
Boarders (irregular/poor definition)
Color (variable pigmentation)
Diameter (>6mm)
Evolution
OSSN symptoms:
Leukoplakic: localized thickening of stratifies squamous epith. W/ white keratosis plaque
Papillomatous: vascularized mass, w/ BV corkscrews to supply metabolic proliferating cells
Gelatinous: poorly defined, transparent thickening of squamous epith.
All stain with NaFl due to irregular tight junctions of abnormal squamous cells
Signs of choroidal melanoma:
Elevated nodular mass under RPE
60% near OD/fovea
Clumps of orange pigment lipofuscin
RPE atrophy/drusen/exudative RD
Causes of anisocoria:
Horners
Physiological (EW asymmetric inhibition)
CN3 palsy
Adies tonic
Aberrant regen (CN3p / adies)
Pharmacological
Pupil damage (trauma/Sx)
AAGC
Horners syndrome symptoms:
Disruption of sympathetic innervation to pupil dilator / mullers / ciliary body / facial sweat glands.
Causes Miosis / partial ptosis (1mm) / anhidrosis (not 3rd order) / accommodative excess / Conj. BV dilation
Congenital cases > Lighter/Darker Brown/Blue eyes
Common causes of horners syndrome:
1st : brainstem/spinal disease (vascular/tumor), diabetic neuropathy
2nd: Pancoast tumor, carotid/aortic aneurysm, neck lesion
3rd: carotid aneurysm, cavernous sinus mass, cluster headaches
CN3 palsy symptoms:
Mydriasis: Pia BV compression > pupillomotor fiber ischemia
Full ptosis: sup. Levator innervation loss
Down/out turn: Sup/Inf/medial rectus, inf. Oblique innervation loss
Thunderclap headaches
Causes of CN3 palsy:
Causes of CN3 palsy:
Pupil involving: compressive lesion/aneurysm on pia BV for parasym. fibers
Pupil sparing: DM/HT > main trunk ischemia
Giant cell arteritis (temple pain) / Pos. communicating artery aneurysm / cavernous fistula common
Adies pupil symptoms:
Poor near focus in one eye
Slow constriction at neat from aberrant regen. (light-near dissociation)
Dilated pupil with poor direct and consensual response
>2months > slow constriction at near response (Light-Near dissociation)
DDX for red eye:
CL related
Corneal epithelial defect
Ant. Chamber disease
Eye wall inflammation
Sub conj. Haemorrhage
Common pharmacologic mydriasis/miosis:
Tropicamide: Muscarinic antagonists > Ach receptor block > sphincter paralysis
Phenylephrine: adrenergic 1 agonist
Pilocarpine: muscarinic agonist > Ach receptor upregulation > miosis
Apraclondine: Alpha agonist > dilation (weak a1, strong a2)
Tamulosin: Alpha antagonist > adrenaline receptor block > dilator paralysis
AACG presentation:
Hx DM/HT
Ache pain w/ Headache, nausea, vomiting
IOP(40-60), closed AC angle, corneal oedema
Mid dilated pupils
Blur based on symptom severity
Ache, nausea
Types of ptosis:
Myogenic (MG, simple congenital, blepharophimosis)
Neurogenic (CN3, horner, marcus gunn)
Mechanical
Aponeurotic (LPS disinsertion)
Pseudooptosis
Pseudoptosis:
Dermatochalasis
CN7 palsy (brow)
CL related red eye DDX:
CLARE
CLPU
GPC
Tight lens syndrome
Dry eye
Corneal defect red eye DDX:
Keratitis
Abrasion from trauma
Recurrent corneal abrasion
Forign body
Anterior chamber disease red eye DDX:
Uveitis
AACG
Eye wall inflammation red eye DDX:
Scleritis
Episcleritis
Conjuntivitis (infection/inflammatory)
Presentation of episcleritis:
Hx RA / autoimmune cond
Irritated to ache pain
Diffuse or sectoral hyperemia
W/o blur/watering/corneal involvement
Phenylephrine 2.5% blanches episcleral/conj. Vessels
Presentation of corneal abrasion (trauma):
Hx trauma
Sharp pain
Watery, photophobic, blur
*W/o infiltrates, rare AC inflammation
Presentation of corneal erosion
Hx trauma/recurrance (<>3mo)
Associated poor healing/DED/dystrophy
Severe sharp pain
Watery, photophobic, blur
*W/o infiltrates, rare AC inflammation
Types of infectious conjuntivitis:
Bacterial (hyper-/acute/chronic)
Adenoviral (follicular/PCF/EKC)
HSV
Chlamydial (adult inclusion/trachoma)
Fungal / parasitic / protozoan
Neonatorum
Presentation of uveitis:
Hx uveitis episodes/autoimmune cond.
Ache pain
Circumlimbal hyperaemia, photophobia, corneal oedema/precipitates (endoth.)
AC inflammation, decreased IOP
Rare pos. synechiae, hypopyon(white BC inf. AC), mitotic pupil (spasm)
Blur based on symptom severity
Types of non-infectious conjunctivitis:
Toxic follicular
Molluscum contagiosum
Stevens-johnson syndrome
Graft vs. host disease
Ocular cicatrical pemphigoid
Sup. Limbic kerato-
Presentation of sub conj. Haemorrhage:
Hx trauma/cough/vomit/blood thinners
(warfarin)
Light or no pain
No symptoms (rare conj. Oedema)
Presentation of scleritis:
Hx RA / autoimmune / GCA
Deep boring/ache pain
Scleral hyperemia (blue colouring)
W/o blur/watering/corneal involvement
Phenylephrine 2.5% will not blanch scleral vessels
Types of allergic conjunctivitis:
SAC/PAC
Atopic
Vernal
GPC
Actue bacterial conjuntivitis causes/symptoms:
Gram+: Staph/strep aureus/pneumoniae
Gram-: haemophilus
Unilateral > bilateral (2d)
Burning pain w/mucopurulent discharge (matting) and diffuse hyperaemia
Rare papillae on tarsal conj.
Follicular adenoviral conjuntivitis:
Serotyes 1-11/19
Unilateral > bilateral (1w)
Ocular discomfort, watery, hyperaemia, tarsal follicles, preauricular lymphadenopathy
Self limiting 1-3w
Pharyngeal conjuntival fever:
Adenovirus serotype 3/4/7
Pharyngitis, fever, conjuntivitis
Mild hyperemia, chemosis, watery, follicles
Common SPEE, swolen preauricular lymphnodes (ears)
Self limiting 2-3w, cold compress w/lubricants (comfort)
Herpes simplex conjuntivitis
Common HSV-1 (ocular) initial infection (<5yo).
Irritation, Watery, follicles, preauricular lymphadenopathy, HSV vessicles (lids),
Dendritic ulcer
Self-limiting 1-2w
Corneal involvement > acyclovir 3% 5/d 1w
No steroids
Hyperacute bacterial conjuntivitis causes/symptoms:
Neisseria gonorrhoeae via genital spread
Pain + tender preauricular lymphadenopathy
Rapid onset uni/bilateral, hyperaemia/chemosis w/great purulent discharge
Chronic bacterial conjuntivitis causes/symptoms:
Any bacterial conjuntivitis lasting > 3w
Related to blepharitis
Burning pain
Light hyperaemia on bulbar and tarsal conj.
Mucoid discharge w/papillae, lid crusting
Molluscum contagiosum conjuntivitis:
Poxvirus nodules containing intracytoplasmic inclusions toxic to conj.
Common 2-4yo
Lid umbilated nodules
Conj. Hyperemia, follicles, mucoid
Self limiting 3-12m, lid nodule excision if needed
Trachoma cause/symptoms:
C.trachomatis bacteria serotype A/B/C
Initial infection (1w incubation) > mild mucopurulent conjuntivitis
Recurrent infection > active chronic inflammation
Late stage > inactive inflammation
Epidemic keratoconjuntivitis causes/symptoms:
Adenovirus serotype 8/19/37
Follicles, hyperemia, chemosis, watery, swolen preauricular lymph
Common subconj. Haemorrhage / membranes (true/pseudo)
SPEE > subepithelial infiltrates
Symblepharon / scarring on healing
Trachoma active inflammation:
Irritation, blur
Follicular/Papilliary hypertrophy
Superior pannus, limbus swelling/follicles
Epithelial keratitis
Mucopurulent discharge
Acute inclusion conjuntivitis:
Chlamydia trachomatis bacteria serotye D-K (1-2w incubation)
Unilateral hyperemia, watery, purulent
Large follicles w/papillary hypertrophy (tarsal conj.) > pannus
Swolen preauricular lymph
Rare SPEE/stromal infiltrate/limbal swelling
* GP systemic azithromysin 1g.
Toxic follicular conjuntivitis:
Long term toxin exposure.
Mascara/timolol/gentamicin/preservatives > type IV delayed hypersensitivity
Uni/Bilateral hyperemia
Mixed follicles/papillae on tarsal conj.
Cold compress and removal of offending agent
VKC symptoms:
Bilateral recurrent, common men <20y w/eczema/asthma
Burning, ropy mucoid, irritation
severe itching
Papillary hypertrophy w/mucous deposits between giant papillae > keratopathy
Limbal gelatinous papillae w/apical white spots (tarantas dots)
Corneal pannus, punctate, vernal shield ulcer
Keratoconus from rubbing
Trachoma inactive inflammation:
Cicatrical fibrosis of conj. > entropion > corneal scarring
Fibrosis/fusion of conj. > symblepharon
Tarsal scarring > white lines (arlt’s line)
DED from meibomian/goblet loss
AKC symptoms:
Rare bilateral, associated atopic deratitis, common late teenage years
Similar to VKC but more severe
Severe itching, mucoid, hyperemia, chemosis
Red macerated lids, blepharitis, narrow fissure
Papules > giant papules
Conj. cicatration > symblepharon
SPEE/erosions/keratokonu
SAC/PAC symptoms:
Recurrent mild bilateral hyperemia, tearing, mucoid
Lid oedema, conj. Chemosis, tarsal papules
Itching, associated respiratory symptoms
Superior limbic keratoconjuntivitis SLK:
Common from blink dysfunction from hyperthyroidism
Ocular discomfort, mucoid, DED
Sup. Hyperemia, papillary hypertrophy, SPEE
Requires treatment of underlying cause
Signs/symptoms of bacterial keratitis:
Pain: severe / increasing
Epithelial defect: boggy edges (stromal oedema)
Discharge: mucopurulent
Ant. Chamber response: hypopyon/ low IOP
Location: central, away from limbal vessels
Size: larger than 2mm
Conj. Hyperemia
Acanthamoeba keratitis risks:
Present in water sources
Poor CL use > biofilm build up
Secondary to damage/HSV
Acanthamoeba keratitis early signs:
Inconsistent symptoms following incubation
FBS > blur > photophobia
Pain: significant / disproportionate (radial keratoneuritis)
Epiphora / blepharospasm: CNV activation
Non-specific epitheliopathy: hazy/pseudo dendrites
Risk factors for keratitis:
CLs
Sx/trauma
DED/bleph/neutrophic keratitis
Co-infection (acanthamoeba/HSV)
Blink dysfunction
Immunosuppression
Immune loss (DM/malnutrition)
CL risk of keratitis:
Low to Dk/t value (soft CLs)
Least with RGP lenses
From hypoxia reducing epithelial adhesion > CLARE/CLPU
Usually gram- psuedomonas aeruginosa
Smoking, poor hygiene, blepharitis
DDX keratitis:
CL related: CLARE/CLPU
Corneal defect: abrasion/recurrent erosion
Infective: acan./herpectic/fungal/marginal/bacterial
Symptoms of CL edema (hypoxia):
Acute:
Pain, blur, photophobia, tearing
Diffuse epithelial superficial keratopathy
Chronic (neovasc.):
No pain, light blur, endoth. Blebs.
Corneal neovasc:
Vessel presence
Fungal keratitis risks:
Trauma (esp vegetables)
Biogel formation
Tropical climate
Immunosupression
Hydrogel CLs
Acanthamoeba keratitis late signs:
Weeks after incubation; in addition to early signs
Stromal involvement: nummular infiltrates (snow storm)
Pain: extreme (pathogen around stromal nerves)
Progression:
Large epithelial defect/stromal thinning
Anterior uveitis (hypopyon)
Inflammatory AACG
Fungal keratitis symptoms:
Pain: Slow progression (weeks) w/nerve damage (lesser pain)
Discharge: common from bacterial co-infection
Infiltrates: feather/button
Conj. hyperemia
Symptoms to differentiate fungal keratitis:
Filamentous: feathery infiltrates > ant. Chamber reation (hypopyon)
Yeast: Button infiltrate > epith. Ulcer
Symptoms of HSK:
FBS, photophobia, epiphoria, blur, hyperemia
desensitisation
Dendritic lesion
IOP increase (trabeculitis)
Lid HSV vessicles
HSK corneal lesion:
Small opaque epith. Cells > desquamation of central cells > punctate erosions progress/branch
Terminal bulbs contain swolen virus laden cells.
NaFL stains central desquamation
Lissamine stains damaged bulbs
CL complications:
Corneal hypoxia
Corneal neovasc.
CL-associated dry eye
3-9’ staining
Sup. Epith. Arcuate lesion (SEAL)
Tight lens syndrome
Toxic/allergic kera/conjuntivitis
CLARE
Culture neg. Peripheral ulcer (CLPU)
Microbial keratitis
GPC signs/symptoms:
Ocular irritation, itching, hyperemia
^mucus deposition on CL > ^deposit > CL intolerance
Irritation worsens on CL removal (papillae contact ocular surface)
Micro/macropapillae on sup./inf. Tarsal conj. w/mucus deposit/discharge
Mucus/cellular deposit on CL > blur
CLARE symptoms:
Severe pain, photophobia, tearing
Intense hyperemia
Focal/diffuse subepithelial infiltrates across cornea
Intact epithelium, with light superficial punctate keratopathy
No mucopurulent discharge (sterile inflammation)
CL associated dry eye symptoms:
FBS, gritty, tearing, burning
Ocular surface staining, hyperemia, deposits on CL
Symptoms worsen towards end of day
3/9’ staining symptoms:
CL intolerance/awearness
FBS/gritty
Mild punctate epithelial loss > NaFl staining peripheral cornea at 3/9’
w/o localised conj. Hyperemia
Tight lens symptoms:
FBS, gritty, tearing, burning
Limbal hyperemia/staining
Severe cases > infiltrates > AC reaction
Symptoms worsen towards end of day
CNPU/CLPU symptoms:
Irritation, photophobia, tearing
Peripheral well-defined circular epithelial lesions/ulcers w/stromal infiltrates
Hyperemia, AC reaction (severe)
Commonly with pos. Blepharitis (S.aureus)
Infiltrates larger than epith. Defect (sterile inflammation)
Causes of HSV reactivation:
UV (induced immunosuppression)
Trauma
CLs
Stress
Symptoms of initial HSV infection:
Primary manifestation of blepharokeratoconjuntivitis
Lid vessicles, follicular conjuntivitis, corneal microdendrites
CL related toxic/allergic conjuntivitis symptoms:
Lens insertion > acute pain
Conj. Hyperemia / chemosis > take 48h to resolve
Diffuse epithelial punctate staining w/ small intraepithelial infiltrates
VZV initial infection:
Chickenpox
Rash, fever, malaise, pneumonia
Traves to dorsal root/CN sensory ganglia (retrograde)
Lies dormant
DDX between CPLU and MK:
Pain: severe/increasing
Epithelial defect: soggy (stromal oedema) / pseudodendrites (acan.)
Discharge: mucopurulent (bacterial > conjuntivitis)
Ant. Chamber reaction: sterile infiltrates of intraocular infection
Location: central ulcer (bacteria avoiding limbal vessels w/leukocytes)
Size: ^2mm infectious
[Pedals]
VZV reactivation:
Loss of cell mediated immunity against virus (stress/age) > Shingles
Causes prodromal malaise (3d) > fever, fatigue, painful rash
HZO when virus travels opthalmic branch of CNV
Clinical presentation of HZO:
Lid vessicles/edema/inflammation
Conjuntivitis w/ papillae/follicles/membranes
Epi/scleritis
Keratitis
Epitheliopathy (pseudo-dend.)
Uveitis
Optic neuritis
Post-herpetic neuralgia
Hutchinson’s sign (nose rash)
Symptoms of HSK dendritic ulcer:
Light pain (neurotrophic), FBS, tearing
Photophobia, blur, hyperemia
Hx prior attacks
Significant pain > healing defect/acan.
Signs of dendritic ulcer:
Opaque punctate epith. > branching lesion w/terminal bulb
NaFl pools in central desquamation / lissamine stains bulbs
Underlying stroma opaque
Corneal desensitisation
^IOP < trabeculitis
Viral vessicles on lids
Steroids/immunocomp. > satelite lesions/bacterial co-infection
Neurotrophic keratitis presentation:
Light pain, photophobia, blur
Corneal desensitisation
Irregular epith. Punctate erosions > ulceration > scarring/neovasc.
Smooth boarders
Presentation of geographic/metaherpectic ulcer:
G: enlarged epithelial ulcer, uneven boarders (unlike neurotrophic), NaFl stains centre
M: poor healing of G, NaFl stains outer
Lissamine green has reverse staining
Necrotising stromal HSK symptoms:
Photophobia, tearing, blur, discomfort
Dense stromal infiltrates, stromal oedema, necrosis, melting (viral replication in keratocytes)
Leads to corneal thinning, AC reaction (^IOP / hypopyon)
Immune Stromal HSK symptoms:
Photophobia, tearing, blur, discomfort
Nummular infiltrates under prior epith. Keratitis
Disciform keratitis presents as diffuse/focal/ring-like
Significant inflammation > stromal vascularisation
Microdendrites indicate active corneal disease to be managed first
Resolves with thinning, opacification, ghost vessels
HZO manifestations:
Photophobia, blur, tearing
Light pain
50% HZO cases > Punctate epithelial keratitis > swollen lesions with live virus >
Pseudo-dendrites: branching swollen virus laden epith.
w/wo stromal infiltrates
MG symptoms:
Limb weakness
Poor facial expression
Poor swalling/speaking/breathing
LPS loss > ptosis
EOM loss > diplopia
Symptoms worsen with use (sustained upgaze)
HZO disciform stromal keratitis symptoms:
5% HZO cases after 4w from onset
Localised inflammation full depth of stroma > immune ring
Corneal oedema w/anterior uveitis
Limbal vascular keratitis > corneal neovasc.
Chronic/recurrent cases > scarring
Endothelial HSK symptoms:
Significant photophobia, blur, light pain (light ulceration)
Light haloes, tearing
Stromal oedema, endo. Precipitates, AC flare
Stromal Wessely ring > scar > blur for years
Disciform endothelitis as circular inflammation
Trabeculitis > ^IOP
HZ nummular stromal keratitis symptoms:
25% HZO cases
Fine granular subepithelial infiltrates under punctate epithelial keratitis
Vision effect depends on location
Etiology factors for autoimmune diseases:
Genetic predisposition
Environmental triggers
Loss of self-tolerance
T-cell activation/differentiation
Autoantibodies
Activation of autoimmune response
HZO keratouveitis symptoms:
Blur, pain (ciliary spasm), photophobia, conj. Hyperemia
AC flare, iris synechiae, cornea oedema
Trabeculitis / meshwork blocked by WBC> ^IOP
Chronic/recurrent > corneal oedema / Iris atrophy
Common autoimmune diseases affecting the eye:
TED / Graves
Sjrogrens
Myasthenia gravis
MS
GCA
T1 DM
RA
Systemic lupus erethematosus
Sjogrens syndrome systemic symtoms:
Dry mouth > poor speaking > dental cavities
Fatigue > joint pain > peripheral neuropathy
Associated RA / SLE
AADE
MS ocular symptoms:
Optic neuritis: VF loss/pain
Diplopia: EOM loss
Nystagmus: eye coordination loss
Internuclear ophthalmoplegia: medial longitudinal fasciculus loss (MR loss)
Uveitis: inflammation secondary to macula oedema
Optic neuritis (from MS):
ON inflammation > sudden painless loss of vision (days)
Loss of contrast, red desaturation, RAPD
+- Pain on eye motion, ON oedema
50% MS Px experience
GCA symptoms:
Persistent headache near temples w/scalp tenderness
Jaw pain on chew/talk
Fatigue/malaise/weight loss/ night sweats
Ophthalmic artery affected > Arteritic ischemic optic neuropathy (AAION) > painless sudden vision loss, RAPD
Diabetes related ocular diseases:
DR: endo. Loss of small BV
Cataract: lens protein glycation
DED: nerve damage > poor tear reflex/neurotrophic GF
CN palsy: secondary D.neuropathy
CR(A/V)O/BR(AV)O or NAION: endo loss
AAION (GCA):
Sudden painless loss of vision
RAPD
VF loss
Pale swollen ON
T1DM clinical presentation:
Polyuria: ^unregulated glucose > ^urine filtration > osmotic diuresis (^urination)
Polydipsia: osmotic diuresis > dehydration > ^thirst
Polyphagia: cells unable to intake glucose > cellular starvation > ^hunger
Weight loss: poor cellular glucose metabolism > fat/protein breakdown for energy
Fatigue: poor metabolism > low energy
Blur: ^glucose > osmotic changes in lens > refraction change
T1DM vascular complications:
^ glucose > BV endothelial damage
Macrovascular: coronary artery/cerebrovascular disease
Microvascular: (endo. Is sole component)
D retinopathy, D neuropathy, D nerphropathy
Graves’ disease symptoms
^metabolism > weight loss, sweating, heat intolerance
Hyperactive sympathetic NS > nervousness, irritability, heart palpatiations
Negative feedback mechanism > high TH, low thyrotropin-releasing hormone
Fatigue, enlarged thyroid gland (neck), alopecia
Thyroid eye disease risks:
Thyroid ophthalmopathy from 25-50% grave’s Px.
^with smoking, immunotherapy, radioactive iodine therapy (graves’ treatment)
TED symptoms:
Proptosis > DED
EOM loss > muscle fibroblast fibrosis
Sup/Inf lid retraction
Soft tissue involvement > sup. Limbic keratoconjuntivitis (mechanical friction)
Compressive optic neuropathy
Superior and inferior lid retraction in TED:
Inflammation > fibrosis > lid retraction > clinical signs:
Dalrymple sign: retraction in primary gaze
Kocher sign: staring/attentive fixation
Von Graefe sign: abnormal descent of upper lid on downgaze
Proptosis DDX:
Infection: orbital cellulitis
Inflammatory: TED
Vasculitis: Wegener granulomatosis
Neoplasic: Lymphoma/leukemia
Orbital vascular disease: arteriovenous malformation
Trauma: orbit fracture
Pseudoptosis: Contralateral blepharoptosis
ERM signs and symptoms:
irregular light reflex on red-free photography
retinal striae > wrinkles > distorted BV
Macular pseudo holes, cystoid macula oedema, haemorrhages
Metamorphopsia
Soft tissue involvement in TED:
Superior limbic keratoconjuntivitis: secondary to mech. Friction on blink from proptosis
Soft tissue expansion > periorbital swelling
DED from lid retraction/lagopthalmos secondary to proptosis
ERM progression
ERM contraction > retinal structure disruption > macula/vasculature distortion >
photoreceptor dislocation, local elevation, haemorrhages, retinal oedema
ERM description and presentation:
Fibrocellular, avascular proliferation of glial cells forming translucent sheet.
Presents decreased VA ~6/12
Macula hole Stage 1:
1a (impending): muller cone detaches from photoreceptor layer forming cystic cavity
Inner/outer retinal layers still intact
1b (occult): loss of foveal depression, displacement of outer retinal layers.
50% stage 1 holes resolve spontaneously
Macula hole description:
Full thickness loss of retina at central macula
Idiopathic occur in females 2:1, 65y, 10% bilateral
Macula hole stage 2:
Small full thickness hole
Desinence forms in ceiling of cystic cavity, pulled by vitreofoveolar attachment.
seperates partially or fully.
Almost always continues to stage 3
Macula hole stage 3:
Full sized macula hole
Vitreofoveolar traction Continues desinence into photoreceptor layer
Roof detachment forms pseudo-operculum
Pos. Hyaloid face may separate from retina (partial PVD)
Signs of macula hole:
1a: flat foveal depression
1b: yellow macula ring
2: retinal defect <400um, circle/oval/crescent shape
3: retinal defect >400um, red base with yellow/white dots surround by grey subretinal fluid and pseudo-operculum. May have noted pigmented demarcation line at edge of subretinal fluid cuff
Symptoms of macula hole:
1: asymptomatic, slight metamorphopsia
2: decreased VA (6/15-6/120)
3: decreased VA (6/60-6/240)
Eccentric fixation can resolve better VA
Macula hole stage 4:
Full sized hole with complete PVD
Usually with noted Weiss ring, circle of condensed vitreous that was attached around ON
Lamellar macula hole signs/symptoms:
Asymptomatic (6/9)
Circular defect at inner retinal layer without thickening/cystic formation
Often with pseudo-operculum
Fluroescein angiography shows no abnormality
CSR risks:
Stress
Corticosteroids
Males 20-50yo
Type A personality (competitive)
Other maculopathies:
Diabetic
Macula oedema
AMD
Solar retinopathy
Adult citelliform dystrophy / adult BESTs disease
BESTs disease / Stargardts
CSR symptoms:
Decreased VA 6/15, may improve with hyperopic refraction
Metamorphopsia / central scotoma
CSR signs:
Amsler distortion
OCT dome
FFA shows sites to fluid pooling
Chronic (SRD) will be more shallow
Hypertensive choroidopathy signs:
Elshnig spots: well-demarcated yellow/white areas of RPE atrophy, later develops central pigmentation
Sigrist streaks: hyperpigmented streaks overlying choroidal arteries
Pale patches under retina (RPE necrosis)
Exudates in sub-retinal space
Hypoperfusion on autofluroescence
Ocular conditions secondary to hypertension:
CRAO / BRAO
CRVO / BRVO
Non-arteritic anterior ischemic optic neuropathy (NAION)
Stroke
Diabetic retinopathy
CRAO/BRAO presentation:
Sudden painless loss of vision, narrow/attenuated arteries
Whitening of retina within hours (ion transport loss in ganglion axons > axonal oedema)
Cherry red spot (lack of NFL w/pigmented compounds at fovea)
Vision loss at fovea related to axonal ischemia preventing signals leaving eye
Severe > RAPD
Early AMD clinical presentation/signs:
Sub-RPE basal linear deposits
Large soft drusen
Hyper/hypopigmentation
RPE/retina atrophy (w/drusen)
Geographic atrophy > visible choroid (wo/drusen)
PED from poor fluid transport (bruchs dysfunction) filled with serous fluid/haemorrhage/drusen
Drusen coalescence > drusenoid RPE detachment
Causes and risk factors of AMD:
Age: loss of antioxidant mechanisms
UV(long wavelength): ^free radicals > phototoxicity > cell damage
Genetic: ABCR gene on chromosome 1q32 for complement factor H (protective factor)
Smoking: double risk (free radicals)
^BMI, HT (^BMI), Cat Sx, female, hyperopia, caucasion
Dry AMD symptoms:
Bilateral asymmetrical gradual loss of central vision
Metamorphopsia (Drusen > PR displacement)
Central scotoma (geographic atrophy)
Exudative AMD symptoms:
Painless blurring central vision (in days)
Metamorphopsia/scotoma
Sudden vision loss (vit. Haem.)
Exudative AMD clinical presentation/signs:
CNV: yellow central dome elevation w/PED
Haemorrhagic PED: dark sub-RPE dome > vit-haem
Fibrovascular disciform scar: healed CNV > white patch (permeant blur)
PC AMD:
Difficulty reading/knitting
Poor facial recognition
Central scotoma (black/grey)
Lines wavey
Poor dark/light adaptation
Asymptomatic
DDX gradual loss of central vision:
Dry AMD
Macula oedema
Macula hole
ERM
Adult best vitelliform dystrophy
DDX sudden painless loss of vision:
Wet AMD
CSCR
RRD
CR/BR VO
CR/BR AO
N/A AION
Chorioretinitis (toxoplasmosis)
RP symptoms:
Nyctalopia: initial Rod loss
Peripheral loss: Tunnel vision from Rod loss
Photophobia: Rod/Cone loss > doubled recovery time for photopic stress
Photopsia: altered PR signals > peripheral shimmering
Central vision loss: Late cone loss
RP signs:
Bony spicules: interstitial pigment clumps
ON pallor: white/waxy from Gliosis/ganglion death
BV attenuation: PR loss > attenuation / CC atrophy
Macula oedema: BRB loss > leakage
ERM: Atrophy/BRB loss > proliferative vitreoretinopathy
Bulls eye maculopathy / PSC / Vit. Degen.
CNSB symptoms:
Nyctalopia w/poor light-dark adaptation
Photophobia, strabismus, nystagmus
Varied fundus: pigmented, scattered dots
ERG shows low red response, normal cone
Associated myopia
BEST vitelliform macula dystrophy signs:
Abnormal EOG > macula drusenoid lesion > pseudohypopyon > ruptured lesion > macula atrophy
VA decreases past 6/60
Stargardt disease and FFM signs:
Present 10-20yo w/ central vision loss (macula)
Mottled/metal macula > bulls eye maculopathy/atrophy
Pisciform (fish shape) flecks on fundus
VA stabilises at 6/60
